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Use of restraint

2015

Hey guys, I’m a second year student in
Child and Youth Care Counselling at Mount Royal University. Last
semester I did an observation practicum at an intensive therapeutic
treatment center for young kids, most of whom had horrific stories of
abuse and neglect. It was an interesting learning experience, I still do
not have a lot of exposure to the field but am both fascinated and
passionate by the tremendous strength and courage in each one of these
children.

I must however ask your professional
opinions on your experience with counselling, and helping these
children. One of the techniques used was restraint. Is the use of
restraint effective when a child is escalated? If their file gives
evidence of past physical abuse does this change the way staff approach
this child? Lastly, how can the use of such a technique be used and
trusted to staff who can be just as escalated as the child? Curious
about your wisdom and opinions!

Thanks,
Rachelle Tang
...

Rachelle,

Welcome to youth care, it is a wonderful and
opportunity to help the children and youth that come from homes of abuse
and neglect.

I think all of our goals as child and youth care
workers is not to do any further harm to these kids. I think we need to
look at all other options before we put "hands on". However saying that
sometimes a youth maybe so out of control that it is necessary. If the
restraint is done probably and staff are not engaging the youth during
this process, I can speak from experience that the results can be found
to be a positive experience.

I was trained in a variety of restraint techniques,
but by far the best was TCI (therapeutic Crisis Intervention ). The
trainers were directly trained through the experts from Cornell
University. This by far is a safe non-business restraint techniques that
keeps the youth safe from harming themselves, and others.

Hope this helps.

Dave
...

Hello Dave,

Yes, I have to agree.... having done training in BMS
(behaviour management systems) and having exposure to NVCI, TCI seems to
be good. I was also trained in TCI but to date have not needed to use
the restraints. I can appreciate that it can sometimes be very difficult
when a child is hurting themselves or could potentially hurt others, but
what I would suggest is that the very first step if "others" could be
potentially be harmed is to make sure that the "others" leave or are not
in the same vicinity as the child. Again, I cannot emphasize enough,
restraints not only should be an absolute last resort, I would go as far
as suggesting that the realization that restraints do not help or change
behaviour is becoming more prevalent as models like like CPS are
adopted.

Delphine
...

Hi Rachelle,

I think your questions are excellent ones. The idea
of restraint reduction/elimination for youth who are presenting "out of
control" behaviors has been a passion of mine throughout my career.
Having worked 25 years in a large residential treatment center of 114
children near New York City as a direct practice CYC worker, Recreation
Director, Girls Program Director and 13 years as Associate Director of
the agency gave me the opportunity to view restraints at many levels. As
a CYC worker I did a number of restraints before I was ever trained how,
or had any idea what I was doing. Thankfully, no disasters but a lot of
experience in why they are so awful for all involved. Interestingly
enough although I remained having a lot of in the moment contact with
kids in all the other roles I did not do a single restraint once I was
trained to do so. Here-in lies the key. When one develops strong
relationships with children, create a sense of safety together, and
develop more confidence in intervention skills the need to restrain will
usually fade away. I also taught the Cornell TCI course for over 20
years and served 12 years on the national Residential Advisory Board of
Child Welfare League of America where restraint reduction was a
consistent topic. I have had much direct experience with restraints in
program work and teaching, and have heard so many of the rationales as
to why they are "necessary". I don't but the necessary part very much at
all.

Some reflections:

1. Restraint should never be viewed as a "last
resort therapeutic intervention". It should be viewed as a "therapeutic
failure". This doesn't mean the worker "failed" but rather the worker
and the program should review whether they have the amount and quality
of resources to serve children without restraining,

2. In many years of reviewing restraints as an
executive level administrator the vast majority of restraints did not
need to be done. There were clearly points in process where a different
type of intervention technique, or higher skill level, would likely have
prevented it completely. One major argument that you hear when the
largest number of restraints in program are with the youngest group of
children (8-11 years old) is that at that age "they don't talk it out as
well". This is often used to justify the restraint to "keep the child
safe". A key question to ask the worker (and program administrators) is
whether the restraint that was done on this 120 pound child would have
been done on a 6 foot 3 inch, 220 pound, 17 year old athlete presenting
similar behaviors....and the answer is generally "No, it would not have
been safe"...so, then the restraint on the younger child really wasn't
"necessary" either...it was just more convenient.

3. To quote an old Cornell saying "Every one
(restraint) is a big damn deal". All restraints should be reviewed at
all program levels to see if they could have been prevented and what the
child, worker, and program can learn from them. Workers should be
responsible for their decisions and should be willing to justify their
actions. The program should be responsible for supports provided to the
worker.

4. I was able to fully eliminate restraints in the
two years I was Director of the 40 bed adolescent girls program in the
center, although not for the whole program when I was the Associate
Director. However, we did reduce them dramatically over the 12 years I
was in that role. One significant contributing factor was that I, at
executive administrator level, taught the TCI course myself along with a
direct service CYC worker once a month. There would be no "message
drift" about the program philosophy about restraints in the training
since it was coming straight from executive level. All workers including
CYC workers, crisis intervention specialists, social workers,
psychologists, program directors, secretaries, maintenance staff,
interns, etc. were all required to take the course before they could
begin their job. No, we did not want the secretaries or cooks doing
restraints, but everyone was trained in the event of a real
emergency....but most importantly: The more people who know a safe one
will also know a bad one!....and we now had "monitors" to help keep
children safer and minimize risk of abuse. It also set the program
philosophy about minimizing or eliminating restraining very clearly for
all.

I realize I have been provocative here and risk some
saying "He is just out of touch now...there is a real world out there
where kids can be very aggressive". I am still heavily involved in
training and consulting with programs so I would love to think I am not
all that out of touch...but I also know that is the same rationale I
have heard for many years for very destructive restraints and in
programs where they became all too "acceptable"...and yes, when that
happens I don't shy away from the words "institutionalized abuse". All
of us should be consistently looking for ways to move aggressively
toward the elimination of restraints and programs that can't make large
progress in that area, or don't prioritize it highly, should start to
question their own validity.

Provocative food for thought! Please feel free to
e-mail me at Fdelano24@aol.com if you want more elaboration.

Frank Delano
...

Hi Rachelle,

I totally agree with Frank. What hit home for me
years ago when I did my first CPI training and years later becoming an
instructor, is that generally more experienced CYC's do less restraints
because they've honed their skills for de-escalation. Paying attention
to those workers who don't need to do restraints will serve you better
than those who resort to the physicality of a physical restraint

Deb Cockerton
...

It is unfortunate for anyone to generally think that
restraint is therapeutic to the individuals we support. Restraint
shouldn't have been used at all except when it becomes absolutely
necessary for the safety of all the parties involved after every other
supports has failed.

Having said that restraint could be therapeutic for
individuals that recognizes such to get at their desire and unable to
pictorially or verbally make such a request. For example an individual I
know that normally would go and grab staff's chest, boobs in case of
female staff. The individual does the grab to get squeezed or restraint
which happens after the chest grabbing. That continued until staff got
the message and taught the individual how to ask for a hug by showing it
instead of boobs grabbing.

The key is to work hard in knowing our guys so that
prevention of situations that may lead to restraint is eliminated. The
action, restraint is of no good to the individual, peers and staff in
general.

Ade Adejobi
...

Thank you Rachelle for your poignant questions and
Frank for your candid and multi-level perspective. I too have concerns
about the potential for restraints to do more harm than good. When
working with children and youth in residential treatment we are often
working with the most vulnerable of the vulnerable. Their boundaries
have been violated, their trust in others and sense of self skewed, they
often have a lack of voice, power, and certainly lack capacity for
emotional regulation - this should be expected as a given. Emotional
regulation capacities are learned through attuned, calm, loving, and
attentive care. As an infant our self-regulatory capacities are directly
impacted by our attachment relationships, or lack thereof, with our
primary caregivers. Our brain grows more rapidly than it ever will again
during the last trimester of pregnancy and the first year of life more
than doubling in size in the fort year then dropping off to only 18%
growth in the 2nd year. 5/6th of this growth in the first year is driven
by attachment (being held, sung to, touched, nurtured, rocked, mutual
gaze experiences etc). This rapid brain growth is largely right brain
development (sights, sounds, smells, sensations of touch etc) in the
first and second year with the left hemisphere (cognitive, language, the
foundations for higher order and more complex functions) begins to come
online in the 3rd and 4th year and continues developing into early
adulthood. Peak periods of growth for the prefrontal cortex occur in our
teen years beginning around 12 and completing development around 26-30.
It is important to keep in mind that the rational cause and effect,
if-then thinking that we expect children to utilize is of the last to
develop. Add to that as youth our brain is primed to overestimate
benefits and underestimate rewards. Essentially I would suggest we need
to be asking ourselves a few key questions:

1) Are we aware of the impact trauma and attachment
had on brain development? Trauma and attachment dysregulation impacts
many areas including our executive functions (the ability to plan,
organize information, initiate, inhibit impulses to name a few). The
ability to concentrate, learn and retain information is also impacted.

2) Are we aware of the impact attachment
dysregulation and trauma have on the developing nervous system and do we
know how to promote regulation (bottom-up and top-down)? Attachment
significantly impacts our developing nervous system setting the
foundations for regulation accessed throughout the lifespan. Trauma and
attachment dysregulation significantly impact the development of key
regulatory skills such as emotional regulation, self-reflecting
fictions, empathy, eye contact, and sensory processing.

When we are primed for threat and danger through
early adverse experiences this also impacts our ability to attend to
information, accurately perceive what is happening around us and also
impacts our social engagement capacities including empathy and morality.

Do we know what dysregulation looks like? If not
this is something we should learn. We can clearly track the state an
individual is in based on observations of affect (for example whether
they are perceiving safety, danger, or life threat). Strategies are
going to be different according to the state they are in but all involve
coregulation, sensory based regulation, mindful awareness, and the
attuned support of a grounded and compassionate caregiver.

If we have awareness of the above and truly
understand it are out expectations reasonable and possible?

3) Perhaps the most critical question is whether you
are grounded and regulated yourself sufficient enough to respond in a
manner that is safe, regulated, and empowering. As helpers we MUST
provide children and youth with a different experience of how people and
caregivers around us behave. If we want them to be regulated we need to
be regulated ourselves. If we want them to identify and express their
feelings and use appropriate boundaries we need to model this and help
cultivate these skills.

Children and youth do not automatically know how
they feel. If this is modelled for us we learn. Many children in care
have not had this modelled and taught to them in a healthy manner. Many
are allergic to relationships as they have learned that people hurt, are
unpredictable, or leave. We as the caregivers in their lives need to
help repair the relational traumas and perceptions of relationships they
have formed. We need to act as their prefrontal cortex for them (as
theirs is still developing and maybe yours is too!). This includes
helping to increase awareness of emotional and physiological felt
states, as well as identification and expression of needs, feelings and
boundaries. It can be as simple as noticing and verbalizing: "It looks
like you are feeling frustrated (or whatever feeling you observe) I
wonder if (insert strategy here) might help?" There are many relational,
sensory, and emotional strategies we can use to promote regulation. It
is a process of trial and error to learn what strategy works for what
youth and in what emotional state. Needs will be different with
different emotions.

Caregivers should notice and regulate their own
affect before responding. It takes seconds...but can save you hours!!
Plant your own two feet on the ground, take a fe deep breaths, notice
what you are feeling, notice any area of tension. Relax your shoulders,
jaw, mouth, eyes, and tummy. Slow your breathing, lower and slow your
speech to a gentle prosodic tone. Ask yourself do you have soft eyes,
soft mouth, soft voice? These are communicated directly to the child's
nervous system through right-brain to right-brain communication. They
can auto-regulate through your calm presence or dysregulate further as
you escalate. The latter tends to be exhausting and shame-filled for all
involved. Most importantly though it does not build competency or
restore power to the child - it takes it away which reinforces what they
already know to be true - they are powerless and adults are stronger
than them.

As with Frank I have worked in residential
treatment, have provided crisis support on hospital psych floors, and
have worked with high risk highly dysregulated and traumatized
individuals for several years. I too have found that regulation without
restraint is not only possible but probable. As a consultant that trains
in trauma, attachment, and regulation I as many others am aware that
people behave in predictable manners. Once we understand common
reactions and responses of traumatized children and how to support the
regulation process we often do not need to engage in restraint. Often
this is reactive and driven by our own dysregulation and perceived loss
of power. When our brain perceives inequality it doesn't like this and
instinctively becomes defensive and reactive (largely at a level outside
of our conscious awareness). If we are aware of our own feelings,
physiological and emotional reactions, and how to ground ourselves this
can go a very long way.

There are many fantastic resources and trainings to
assist with the development of such skills. If interested in learning
more please inquire and I'll gladly share some recommended resources.

This is by no means meant to offend anyone but
rather to gently challenge you to consider your perceptions, your
knowledge, your reactions, your triggers, and potential areas for
continued development and growth. This is a continual process and we all
are in this because of a passion to help children - however we too are
humans and have perceptions that drive our reactions. We do the best we
can with what we know when operating on autopilot. Awareness, conscious
reflection, learning and reshaping allows us to be the best helper and
support we possibly can be.

Wishing you a gentle day and thank you for the work
you do!

Lori Gill
…

Hi Frank

I appreciate your thoughts on this. Your re-frame of
‘last resort’ to ‘therapeutic failure’ is very powerful and I agree with
how you define that. It reminds me of a Barbara Docker-Drysdale comment
that ‘All acting out takes place in the context of a breakdown in
communication”). Barbara D-D was a pioneer of therapeutic residential
care for children in UK. I am part of the Cornell TCI Instructor Team
and am based in Ireland. I think it was Jeremy (second name gone from
me!) in an earlier thread or maybe this one who said something like “it
is time to put resources in solid programme / model design elements like
appointing suitable people for the job”. If I remember rightly his
argument went on “and less on expensive programmes of restraint.” I have
no doubt that in Ireland TCI played / plays a major part in making
residential care much better than it was – but that was only ‘round one’
or as the family therapist say, ‘the first wave’. The second wave in N.
Ireland is evidence of five different models / programmes of care
piloted by the five statutory child care bodies. Report available here
http://www.scie.org.uk/publications/reports/report58/index.asp . The
third wave – in my opinion – is how to make genuine models of
therapeutic care available to ALL children and youth in alternative
care. I worry that managers, policy makers and politicians think that
training staff in programmes like TCI is enough and that restraint
elimination is enough. These are my personal opinions.

Johnnie Gibson
...

Frank.

Thanks for your well thought out reply to Rachelle's
post. Myself having 45 years as a CYC and program director in multiple
residential settings, my transition to Relationship Youth Care Work did
take much too long. I sincerely hope that Frank’s post is read by all in
the field.

Steve Bewsey
...

A lot of great feedback and experiences here on this
topic!

I will briefly add here, in the agreement to
utilizing restraints as a last resort and how it speaks to "therapeutic
failure". Restraint is about control; thus, there are concerns as to the
use of control which often addresses the realm of power. Children and
youth we work with are often oppressed and vulnerable: they act and
react to the world around them. Every behaviour has a purpose (Garfat,
2002). We want to avoid control and instead form a caring connection
with young people.

Having worked in various sectors over the last 20
plus years, I have seen the use of restraints, which in my mind was not
necessary.

Further, authentic relational rapport and caring
support system that we build with young people, on top of fitting and
meaningful strategies as we walk alongside children and youth, can most
certainly decrease, even eradicate, the use of restraints as an
intervention. As shared, programs and systems also play a role; yet, we
can advocate and create a difference in the places we work by being an
example and light to other methods. Further, we can also promote, build
and maintain a safe and secure environment for young people.
Additionally, our own "self", both inner thoughts and outside action,
become part of the environment; thus, being a reflective practitioner
benefits the ways we interact.

One place in particular comes to my mind as it was
rampant with restraints; however, it began to change through the
aforementioned. One of the key factors is "us". How do we contribute and
participate in such environments ? I have been trained, via the
workplace, in many different behaviour management/restraint systems;
however, I chose not to restrain (even if everyone else was...) and
utilized alternative measures based on the individual and the status of
our rapport, such as the following:

• sing, hum, read a book, or any other activity that
soothes the child
• be their "inner voice" as a means to educate and bring about
transference in communicating high states of emotion during a
potentially escalating situations; it also helps with exploration of
where these emotions come from and one's reaction to it
• have a space set up for calming with various items (I have co-created
spaces with young people in which any individual in the environment can
engage as needed; it also promotes it as a general space for all to use,
diminishing the idea of being "punished" or centered out)
• find something I like about each child/youth (there is something to be
said about the "vibe" we give off and how our own feelings about a young
person can transfer into behaviour)

These are just a few examples, but the possibilities
are endless for us to explore with those we serve.

Before I end here, I am curious as to the use of
"restraining rooms" and other people's experiences. I find them quite
scary myself, so I can only imagine what kids feel about them... I also
question what the mere presence of such spaces says to children and
youth. I am thankful that my discourse with young people in this type of
environment was brief. Although I have been able to use a restraining
room for alternative strategies, the very sight of them and their
"label" is still out there being used as a deterrent for "undesirable"
behaviour.
So, here we are back again to the fact that every behaviour has a
purpose. Should we not be investigating the root cause and being
supportive? Is not a young person's behaviour a means for their voice to
get out, hoping someone will not only hear them but come to their aid?
These are the children and youth we work alongside of.... thus, I feel
the question we should be reflecting on is, "How are we going to
respond?"

We just concluded working on a 3 year project with
Texas Residential Treatment Centers to reduce restraint and seclusion
using the "6 Core Strategies to Reduce the use of Restraint & Seclusion"
and one of our favorite resources to share with residential
youth-workers is Gordon Hodas' paper titled, "EMPOWERING DIRECT CARE
WORKERS WHO WORK WITH CHILDREN AND YOUTH IN INSTITUTIONAL CARE". See the
link below.

I am so glad that the concept of "therapeutic
failure" with regards to restraints has been brought up. I agree very
strongly with Mary Anne that restraint is about control, and I hope that
more child and youth workers come to the realization that the strength
of the therapeutic relationship can minimize or eradicate the use of
restraints. Unfortunately, there are quite a number of child and youth
workers who still do not have the necessary training or formal education
in theoretical perspectives of why and how our own internal feelings
externally affect the young people and children we work with. Thank you
Mary Anne for your important contribution.

Delphine
…

Hi Mary Anne D,

My input to the restraint topic is a little bit late
but I just wanted to let you know that I really enjoyed reading your
response.

I am a second year student at Mount Royal
University. I am in the child studies program, majoring in child and
youth care counselling.

I am currently doing my practicum at a place I enjoy
very much and have been learning a great deal. However, within my first
day I saw my first restraint and it really bothered me. I do understand
that when a youth is out of control and harmful to others that a
restraint may need to take place but another part of me thought there
could have been something else done to keep this youth under control.

I really enjoyed reading your response to the use of
restraints as I too feel that many of them are really unnecessary and
could have gone in a different direction.

I worked with one youth who would get restrained on
a daily basis and I always thought there could be a different route to
take. With reading your response I really liked your idea about having a
space set up with different items, allowing any youth to engage in the
items in that area which takes away the feeling of being punished. I
think this is extremely important as I feel that if you take away the
feeling of punishment that the individual will try new coping mechanisms
when they get angry. I think this could be a great idea for the youth I
work with.

This particular youth hates going to the QR ( quiet
room). It's a really horrible experience for them and it just makes the
situation worse. I think having a space that makes them comfortable is a
better route to take because like you said it takes that feeling of
punishment away. When you make a youth feel punished it makes them more
upset and less valued as an individual which is not what we want. With
this youth in particular, they have been through so much trauma that
they do not need to go through anymore.

Your ideas really helped me and I hope more and more
people consider using different techniques than using the restraint.

Thank you,

Jordan Turner
...

Hi Jordan,

No response is too late... I myself haven't been on
for a bit, as I am also a student and self-care is my number one
priority. We can't function well without it. I like to think of
discussion boards as one way to engage in mutual dialogue in which we
can learn and grow from one another. I appreciate you sharing your
experiences, and hearing those of others, as it can help us to relate to
professional issues, thoughts, comments, etc that arise in this field;
further, it can cause us to reflect on our own experiences which impact
how we do our practice.

As I read your response a few things came to mind:

First of all, how interesting that we give "neat"
acronyms/names to spaces as if it would enhance the appeal to those
using it. I am sure there are some of us that can relate to the naming
of spaces, and how it can pose a contradiction to and for the young
people we work alongside. Regardless of the names we place on various
rooms to "correct" a youth's behaviour, more times than not they are
perceived by young people as a place of punishment, not a place that
heals or supports. Jordan, your example spoke to this idea. How we use
space is important to the development and growth of children and youth
as it does have impact. Which brings me to the next thought...

Spaces are the places children and youth live in
every day. As child and youth care professionals, every moment is an
opportunity to care for, support, and empower young people. There's a
great book that was highly recommended by my teaching prof that I have
acquired for my shelf of valuable sources. It is called Right here,
right now: Exploring life-space intervention for children and youth
by Kiaras Gharabaghi and Carol Stewart. It is an easy insightful read
for anyone interested.

As I indicated in my initial response, how we respond does have impact
and in ways we can only imagine. What we say and do (or not say and
do) ultimately effects those we work alongside; all we are, as part of
their space, is perceived through the eyes of the child. I feel it is
important to remind ourselves we are here for children and youth, and
that does require mindfulness on our part as professionals in this
field. It is in tough circumstances, as we have shared, that
I am reminded of why I am here in this profession: to be there for the
children and youth, not for any other purpose. Thus, it is my job to
serve them in an ethical and responsible way. I have also seen how
children and youth pick up on how we attend to such difficult
situations, thus, our example can influence how they chose to attend to
their own struggles. Not only do we want to care for and support young
people, but utimately we want to empower them in their own life journey.

Let us keep supporting one another to be the best we
can be, and make a difference in the field of Child and Youth Care.

Thanks
Mary Anne
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